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irugía y Cirujanos. 2015;83(3):238---242

www.amc.org.mx www.elsevier.es/circir

CIRUGÍA y CIRUJANOSÓrgano de difusión científica de la Academia Mexicana de Cirugía

Fundada en 1933

LINICAL CASE

etastatic collision tumour: A case report�

scar Zenón Rosas-Guerra ∗, Jorge Alfonso Pérez-Castro y Vázquez,umaro Hugolino Andrade-López, Fernando Vera-Rodríguez,eriberto Garza-de la Llave

ervicio de Cirugía General, Hospital Ángeles Metropolitano, Grupo Ángeles Servicios de Salud, México D.F., México

eceived 30 September 2013; accepted 6 May 2014

KEYWORDSCollision tumour;Carcinoma;Tumour mixedmesodermic

AbstractBackground: Collision tumours are extremely rare. They are defined by the presence of twotumours of different histological origin in the same organ.Clinical case: A 71-year-old female with history of a carcinoid tumour removed 20 years agowithout any recurrence. The patient was admitted with intestinal occlusion symptoms secondaryto a right flank abdominal tumour. An exploratory laparotomy was performed, removing thetumour and applying optimal debulking.The histopathological study reported bilateral ovary adenocarcinoma, as well as metastaticcollision tumour of two histological types: well differentiated adenocarcinoma and a mixedmalignant mesodermic Mullerian tumour.The patient was treated with adjuvant chemotherapy with poor results (death in 24 months).Conclusions: The presence of collision tumours is extremely rare. There are no statistics orspecific treatment reported. Diagnosis is made with histopathology. At the moment, no similarcases have been reported.

© 2015 Academia Mexicana de Cirugía A.C. Published by Masson Doyma México S.A. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

� Please cite this article as: Rosas-Guerra OZ, Pérez-Castro y Vázquez JA, Andrade-López GH, Vera-Rodríguez F, Garza-de la Llave H. Tumor

etastásico de colisión. Informe de un caso. Cir Cir. 2015;83:238---42.∗ Corresponding author at: Calle 13 número 9, Col. Valentín Gómez Farías, Del. Venustiano Carranza, C.P. 15010, México D.F., México.el.: +52 01 771 7187206.

E-mail address: quirofanofilia@gmail.com (O.Z. Rosas-Guerra).

444-0507/© 2015 Academia Mexicana de Cirugía A.C. Published by Masson Doyma México S.A. This is an open access article under the CCY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Metastatic collision tumour 239

PALABRAS CLAVETumor de colisión;Carcinoma;Tumor mixtomesodérmico

Tumor metastásico de colisión. Informe de un caso

ResumenAntecedentes: Los tumores de colisión son raros, se definen como la presencia de 2 tumores dediferente estirpe histológica en el mismo órgano o sitio.Caso clínico: Se presenta el caso de una paciente femenina de 71 anos, con antecedente detumor carcinoide resecado hace 20 anos, sin recidiva. La paciente presenta cuadro de oclusiónintestinal secundario a tumor en flanco derecho del abdomen. Se le realiza laparotomía explo-radora con resección del tumor, y citorreducción óptima. En el estudio histopatológico seencuentra adenocarcinoma de ovario bilateral, así como tumor de colisión en metástasis, elcual presenta 2 estirpes histológicas: adenocarcinoma bien diferenciado y tumor mixto malignomülleriano mesodérmico. La paciente es enviada para quimioterapia adyuvante, presentandomala evolución. Murió a los 24 meses.Conclusiones: La presencia de tumores de colisión es extremadamente rara, en la literatura nohay estadísticas ni tratamiento específico. Su diagnóstico es histopatológico. No se ha reportadoningún caso similar en la literatura médica.© 2015 Academia Mexicana de Cirugía A.C. Publicado por Masson Doyma México S.A. Estees un artículo Open Access bajo la licencia CC BY-NC-ND (http://creativecommons.org/licenses/by-nc-nd/4.0/).

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Background

Collision tumours are highly rare neoplasias; there are fewseries and case reports on them in the English literature.The presence of several primary neoplasias in the same indi-vidual is a frequent occurrence; they can be synchronous(within a 6-month interval) or metachronous (within aninterval longer than 6 months). However, the presence oftwo histological lineages in the same organ or place iscalled a collision tumour. Histologically, both populationscollide without there being transition areas between them.They have been described as occurring in several places:the cardia, cervix, bladder, liver, lung, thyroids and bil-iary ducts. Most of them are carcinomas and sarcomascollisions or lymphomas collisions, and more infrequently,carcinomas collisions.1 There are several theories, such asthe simultaneous proliferation of two different cell lines,a common origin from a pluripotent precursor cell thatwould differentiate into two components, or the casualdevelopment of two non-related tumours. Genetic predis-position, old age, exposure to environmental carcinogens,previous treatments with radiotherapy or chemotherapyand immunosuppression, among others, are all factors thatincrease the risk of developing these tumours.

The purpose of this study is to show the first case of acollision tumour in a metastasis in Mexico, and possibly thefirst case report in the English language medical literature.

Clinical case

The case is a 71-year-old patient who has a history of intesti-nal surgery due to a carcinoid tumour in her small intestine

more than 20 years ago; she denies having additional medi-cal history of relevance.

She was admitted in February 2012, with symptomsof intermittent partial bowel obstruction, with significant

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bdominal bloating, constipation, nausea and vomiting,nd volume augmentation in right flank, non-mobile. Anbdominal ultrasound was performed, which only showed annechoic lesion in the left lobe of her liver. The abdominalomputerised axial tomography showed the presence of freeuid, a hepatic cyst that had already been detected by theonography, and a tumour that compressed the colon in heright flank; all these data are an indication of carcinomatosisFig. 1). Laboratory data were within normal ranges.

The patient did not show any improvement from thebstruction symptoms despite medical treatment, so anxploratory laparotomy was performed, through which 3 lerohaematic ascites, omental, mesentery and pelvic vis-era implantations were found, with no evidence of primary;

12 cm × 8 cm tumour was seen in the right parietocolic gut-er with encephaloid aspect, papillary, with good cleavagelane, which could be removed. Cytoreductive surgery waserformed, which included Piver 1 total hysterectomy and

bilateral salpingo-oophorectomy with optimum removalR0).

Patient was taken to the surgical inpatient unit; shehowed good progress. She was discharged in 72 h, withdequately tolerated oral route. She was sent to Medicalncology for adjuvancy in March, 2012. Treatment witharboplatin and paclitaxel was initiated. The patient wassymptomatic at her one-year follow-up. However, diseaseecurrence occurred at month 18, with ascites, abdominalain, weight loss and symptoms of partial bowel obstruc-ion. Patient decided not to continue with any treatmentnd died 24 months after the diagnosis.

Histopathology. There is a neoplastic lesion that cor-esponds to a well-differentiated adenocarcinoma on theurface of both ovaries. It forms a solid nodule in the rightvary and in the left ovary, over its serosa, and there are

any Psammoma bodies. There is metastasis in the omen-

al and in the abdominal wall, in which there is a lesionormed by papillary structures of very variable size with two

240 O.Z. Rosas-Guerra et al.

Figure 1 Abdominal tomography that shows ascites (thin arrow), as well as a tumour in the right flank, that compresses the rightcolon (thick arrow), these data are an indication of carcinomatosis (arrow head).

Figure 2 Immunohistochemistry. The use of this technique is shown in the ovarian tumour (upper image), as well as in theas

denocarcinoma area of the metastasis (lower right) with negativarcomatous area of the metastasis.

e receptors, and the positive receptors to oestrogens in the

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Metastatic collision tumour

types of differentiation; one of them is epithelial and coversthe surface of the papillary areas, the epithelium is strat-ified in many places and it has cells with hyperchromaticand somewhat pleomorphic nuclei with frequent mitotic fig-ures and non-vacuolated eosinophilic cytoplasm. The secondcomponent corresponds to a sarcomatosis, with a compactarrangement of cells, scarce cytoplasm with ill-defined bor-ders and occasionally with uninucleate or multinucleategiant cells. There are areas of desmoplastic fibrous stromaand of aponeurotic tissue from the abdominal wall.

The immunohistochemistry analysis shows p53 and WT1markers that are positive in both components; p16 is onlypositive in the sarcomatous component. The endometrialorigin rests on the CD10, CA-125 and oestrogen receptorpositivity. The sarcomatous component is desmin and S-100positive, and WT1, p16 and CD10 negative.2,3 Oestrogenreceptors in the well-differentiated adenocarcinoma partwere negative, and in the malignant mixed mesodermal(müllerian) tumour, that were positive (Fig. 2). The ovariespresented a well-differentiated adenocarcinoma.

We came to a diagnosis of collision tumour in theabdominal wall metastasis, which was formed by a well-differentiated adenocarcinoma component and a malignantmixed mesodermal (müllerian) tumour component.

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Table 1 Reported collision tumours.

Author Age Gender Location

Peng and Schwarz4 52 M Duodenum

Jimenez Hernandez et al.5 33 F Skin

Martinez Munoz et al.6 65 F Skin

Quinones Venegas et al.7 83 F Skin

Quinones Venegas et al.7 55 M Skin

Quinones Venegas et al.7 37 F Skin

Allen et al.8 63 F Ovarian

Jang et al.9 70 F Uterus

Brahmania et al.10 64 F Colon

Ferrando Marco et al.11 64 M Duodenus-head ofpancreas

Williams et al.12 58 M Ampulla of Vater

Varikatt et al.13 37 F Ampulla of Vater

Hirono et al.14 75 M Ampulla ofVater-common bileduct

Patwardhan and Gadgil15 55 F Uterus

Lifschitz-Mercer et al.16 69 F Uterus

Sreenan and Hart17 67 F Uterus

Sreenan and Hart17 72 F Uterus

Gaertner et al.18 49 F Uterus

Lam et al.19 85 F Uterus

Lam et al.19 47 F Uterus

Takahashi and Inoue20 68 F Uterus

Shaco et al.21 79 F Uterus

This study 71 F Peritoneal metasta

F: female; M: male.

241

iscussion

he physical examination, the findings in imaging andesearch studies do not confirm the existence of colli-ion tumours, the latest being histopathological incidents.4

here have been few reports about collision tumours inexico, with only some skin cases.5---7

The combination of a carcinoma and a mixed mesodermalumour is infrequent.8 Until now, there has been no reportn medical literature of a case similar to the one presented.ost of the collision tumours are described under gynaeco-

ogical disorders. Table 1 shows some collision tumours withheir histological location and lineage.

The combination of tumours in one organ or place cane divided into two clinical-pathological groups: collisionumour or compound tumour. In the first one, the histo-ogically different tissues juxtapose with healthy stromaetween them. In the compound tumour, the different com-onents intermingle to form one tumour mass.9

Some theories about collision tumours regard them as proliferation of two different cell lines, or as having a

ommon origin in a totipotential cell, which differentiatesnto two different cell lines.10 A third theory involves thearcomatous conversion of an epithelial tumour. Lastly, it

Type of collision

Adenocarcinoma + neuroendocrine carcinomaSolid basal cell carcinoma + melanocytic nevusKeratoacanthoma + seborrheic keratitisPigmented basal cell carcinoma + seborrheic keratosisPigmented basal cell carcinoma + seborrheic keratosisBenign melanocytic lesion + seborrheic keratosisEpithelial serous adenofibroma + sarcoma withrhabdomyoblastic differentiationPapillary serous carcinoma + endometrioidcarcinoma + mixed müllerian tumourGranulosa tumour + adenocarcinomaDuodenal carcinoid + adenocarcinoma

Carcinoid tumour + adenocarcinomaSomatostatinoma + neurofibromaAdenocarcinoma + cholangiocarcinoma

Adenocarcinoma + leiomyosarcomaWell-differentiated adenocarcinoma + high-gradestromal sarcomaEndometrial adenocarcinoma + homologous sarcomaSerous carcinoma + heterologous sarcomaEndometrioid adenocarcinoma + rhabdomyosarcomaEndometrioid adenocarcinoma + high-gradeendometrial sarcomaEndometrioid adenocarcinoma + high-gradeendometrial sarcomaHepatoid carcinoma + carcinosarcomaPapillary serous carcinoma + small-cell carcinoma

sis Adenocarcinoma + mixed müllerian tumour

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s important to differentiate it from a tumour that metasta-ises in another one. Mixed müllerian tumours are aggressiveeoplasias; extragonadal presence is infrequent. In a caseresentation, Kurshumliu et al.3 refer to only 30 publishedases in medical literature, the majority of which involvedostmenopausal women. A theory proposed by the sameuthors is that the origin is in an endometriotic area.

The origin of this tumour can probably be explaineds an ovarian primary tumour metastasis (adenocarcinomaomponent) and the sarcomatous degeneration of somendometriotic area in the wall; both tumours collided in theame neoplasia.

In general, mixed tumours have a bad prognosis and aostoperative survival of 14 months, although in our casehe survival was of 24 months (12 months free of tumour).

Treatment for these tumours is performed by implemen-ing a combination of therapies, treating each tumour as ift were the only one. This case was treated with surgery toolve the obstruction symptoms, and then it was decided tonitiate chemotherapy with carboplatin and paclitaxel (sincet is a useful method in epithelial ovarian tumours, as wells in uterine sarcomas).

onclusion

ollision tumours are infrequent neoplasias; there are feweports about them in medical literature. Their prognosiss unknown, since there are no previous similar cases. It isossible that long-term survival is similar to that for mixederitoneal müllerian tumours.

The treatment adapted to this case was surgery withptimal cytoreduction, as well as adjuvancy.

onflict of interests

he authors declare that there are no conflicts of interest.

eferences

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4. Peng L, Schwarz RE. Collision tumor in form of primary ade-nocarcinoma and neuroendocrine carcinoma of the duodenum.Rare Tumors. 2012;4:64---6.

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7. Sreenan JJ, Hart WR. Carcinosarcomas of the female geni-tal tract. A pathologic study of 29 metastatic tumors: furtherevidence for the dominant role of the epithelial componentand the conversion theory of histogenesis. Am J Surg Pathol.1995;19:666---74.

8. Gaertner EM, Farley JH, Taylor RR, Silver SA. Collision of uter-ine rhabdoid tumor and endometrioid adenocarcinoma: a casereport and review of the literature. Int J Gynecol Pathol.1999;18:396---401.

9. Lam KY, Khoo US, Cheung A. Collision of endometrioid carcinomaand stromal sarcoma of the uterus: a report of two cases. Int JGynecol Pathol. 1999;18:77---81.

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